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01297
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01297
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # '�
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
i Lcar _rRd_ 7P_x4L0_PS o S, 111 .-
WELL OWNER
Nam �i 1\'M_V,'LV%
rn 7 ei
ing Address pp
OY07
RI rivate
O Public
USE OF WELL
1 - primary
2- secondary
S RESIDENTIAL
Q BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
0 FARM 0 TEST /OBSERVATION
U INSTITUTIONAL 0 STAND -BY
O ABANDONED
0 OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED ,Sr /EST. OF DAILY USAGE c5 0 Dual
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION GI ADDITIONAL SUPPLY
0 NEW SUPPLY NEW DWELLING) DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
IDDRIVE14 ODUG
OGRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES K NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Namel�Uot %�"l P_�l yew W e vlW Address :RbS" ID $ - Ce,�i'Wla,r
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES k NO sow a•"a V
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAFTST WATER FA.!N:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
q
OON SEPARATE SHEET /!�I /�J
-aa -�3
(date) (signs re)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1.
2.
3.
Pump the well until the water is clear.
Disinfect the well in accordance with the
Department attached to this permit.
requirements of the Putnam County Health
Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to• assure that
any and all water or waste products from such well drilling operations be contain�d on this
property and in such a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue:��_ 19
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller